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Based on observations, interview, record review, and review of the facility's policy and procedure it was determined the facility failed to adequately supervise to ensure the safety and welfare of the patient related to medication stored in reach of the residents and to appropriately supervise one patient (#4), in the select sample of 10 patients, after he/she had a previously documented incident of possible ingestion of nail polish which was provided to he/she by the facility and he/she having a history of ingestion of a broken pencil which required surgery, attempting to choke self with sweatshirt, drown self in sink, and claimed to have drank liquid cleaner and of cutting self. Patient #4 was able to take an undetermined amount of Wellbutrin from the pharmacy return bin without the facility being aware of the incident until it was self reported by the patient after he/she stated she began to experience hallucinations.

These facility failures prevented the facility from ensuring a safe environment and appropriate nursing supervision to prevent patient access to unauthorized medications and ingestion of unsafe substances. These failures resulted in non-compliance with the Condition of Participation, Nursing Services and associated Standard Nursing Services; Registered Nurse Supervision (A-0395) were not met. Refer to A-395.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure the safety of one patient (#4), in the selected sample of ten patients. The facility failed to ensure medications were securely stored. Patient #4 had a documented history of ingesting nail polish, a broken pencil which required surgery, attempting to choke self with sweatshirt, drown self in sink, and the patient claiming to have drank liquid cleaner and of cutting self. Even though the facility was aware of the patient's history, Patient #4 was able to reach into the medication room and take a package of Wellbutrin (anti-depressant) from the pharmacy return bin. An interview with Patient #4 revealed he/she ingested several of the tablets and staff was not aware of the incident until Patient #4 self reported what he/she had done after experiencing hallucinations.

Findings include:

A review of the facility's policy entitled "Self-Injury Precautions" revealed: Purpose: To provide guidelines for the use of interventions intended to prevent any self-inflicted injury. Patients believed to be as risk for self-injury will be placed on precautions that prescribe specific steps staff will take to reduce risk and provide treatment for the patient's condition. Additional intervention steps may be taken to address a particular patient's circumstance when authorized by a physician/LIP order. Direct Care Staff will monitor patients' behaviors and be alert at all times to the potential for self-injury in each patient. When self-injury intentions are believed to be present, staff will initiate precautionary measures and interventions immediately. When a patient is believed to be at risk for injuring themselves, specific precautionary interventions may be initiated by staff. These interventions are designed to maintain close supervision and monitoring of self-injurious or suicidal patients.

A review of the facility's policy titled "Level of Observation" revealed: Policy: Every patient will be assigned a level of observation. It is the responsibility of the staff of each Treatment Unit to keep patients informed about the assigned levels of observation, the meaning of the levels, and methods as how levels may change.

Review of Patient #4's record revealed, an admission date of 12/11/12 with diagnosis which included Major Depressive Disorder, Recurrent, Severe, without Psychosis. The reason for admission was noted to be related to the Patient hitting a family member on the head with a rock. Further review revealed the patient had a history of swallowing a broken pencil which required surgery, attempting to choke self with sweatshirt, drown self in sink, and claimed to have drank liquid cleaner and of cutting self. Additionally, the medical record revealed the patient had obtained a bottle of nail polish while at the facility from the facility's prize box on 01/05/13 and the facility documented the patient swallowed a half of a bottle of the nail polish.

An interview with Patient #4, on 03/01/13 at 7:00 PM, revealed he/she just acted like he/she had drank the nail polish, but did not because he/she did not want to be sick from actually drinking it.

A review of the care plan for Patient #4, dated 12/11/12, revealed the patient had a care plan for Suicidal Ideations (SI) and Self Injurious Behaviors (SIB) and had been on routine observation, every 15 minute checks (q15), on 2/16/13, prior to the incident and still remains on q15 minute checks.

An interview with Registered Nurse (RN) #2, on 03/01/13 at 8:10 AM, revealed she was giving the 8:00 PM medications when Patient #4 requested some cough syrup. RN #2 stated while conducting the 8:00 PM medication pass Patient #4 was given his/her medications, near the end of the pass. She stated she never saw the patient enter the medication room.

An interview with RN #1, on 03/01/13 at 8:40 AM, revealed Patient #4 reported he/she had swallowed some medications and flushed some down the toilet. He stated the patient told him he would find the rest of the pills and the package in the toilet. He recalled Patient #4 stated he/she had taken the medication package from the pharmacy return medication bin inside the medication room and went to the bathroom to take the pills. He stated when he recovered the medication package from the toilet, he recalled a maximum of 3-4 pills missing per his recollection of the event. However, he confirmed the package was from stock medications being returned to the pharmacy and there was no counts performed on those medications prior to being put in the pharmacy return box so there were no way to determine the exact number of pills missing.

Observation of the package retrieved from commode revealed five pills remaining and was labeled Wellbutrin SR 150 mg Tablet 30 tablets.

An interview with Patient #4, on 03/01/13 at approximately 9:00 AM, revealed he/she went to the medication room on the unit to obtain cough medicine. Patient #4 reported when the staff turned her back to get the medication, Patient #4 reached into the room, removed a package of Wellbutrin from the pharmacy return bin, and put it under his/her shirt. Patient #4 also reported he/she had taken 14 of the pills and tried to flush the remaining pills down the toilet. Patient #4 stated he/she was having hallucinations within ten minutes of taking the pills and reported what he/she had done to RN #1. He/she stated she gave RN #1 the pill pack containing five pills after he/she had pulled it out of the toilet. Patient #4 stated RN #1 did not believe her/him although there were only five pills remaining in the pack. Patient #4 stated there were only five pills missing from the top row of the pill pack before he/she had taken any of the medication. Additionally Patient #4 stated the facility kept him/her on the same level of supervision and did not do anything else.

Further review of the Care Plan, dated 12/11/12, revealed there was no intervention added to change the frequency of observations of Patient #4 after this incident.

Interview with Mental Health Technician (MHT) #1, on 03/01/13 at 5:45 PM, revealed she spoke to Patient #4 after he/she had taken the medication. She stated the patient was jittery and was having trouble sleeping. She revealed she went to check on the patient but was not aware of the patient being on any increased level of observation at the time.

Interview with Licensed Practical Nurse (LPN) #1, on 03/01/13 at 5:35 PM, revealed she was not aware of Patient #4 being placed on any increased supervision at any time.

An interview with the Administrator, on 03/01/13 at approximately 10:00 AM, revealed she was aware of the incident regarding Patient #4 taking of the Wellbutrin from the medication room. The Administrator also reported she did not believe the patient's level of supervision had been changed.

Based on observations, interviews and record reviews, and review of the facility's policy it was determined the facility failed to appropriately supervise one patient (#4), in the selected sample of ten patients, after he/she was given nail polish by the facility as a prize with the patient having a history of ingesting a broken pencil which required surgery, attempting to choke self with sweatshirt, drown self in sink, and claimed to have drank liquid cleaner and of cutting self. The facility documented the patient drank half the bottle of nail polish. Additionally, Patient #4 was able to take a cassette of Wellbutrin 150 mg. Slow Release tablets from the pharmacy return bin in the medication room without staff's knowledge.
This supervision failure resulted in the patient self reporting an unwitnessed incident to staff due to the patient's fearfulness after experiencing hallucinations. The facility failed to identify the need to provide increased supervision as detailed in the self injury precaution policy.

Findings include:

A review of the facility's policy titled "Level of Observation", last revised 12/2012, revealed every patient will be assigned a level of observation. All assignments/reassignments of levels of observations require a Physician/LIP order. Purpose: To establish procedures to ensure individual patient safety within the least restrictive treatment environment that is commensurate with their clinical care needs. To prescribe the responsibilities of patient/staff for implementation or regular and special categories of observation as set forth by this policy. Terminology: Routine Observation - Ordered unless a special observation category is required. The patient poses decreased or minimal risk of danger to self/others. The patient's location and activity will be observed and documented by staff at least every 15 minutes. Special Observation-ordered when patients display behaviors or develops conditions that require an increased level of supervision. There are three categories of special observation. Special Observation Categories: 1. Q 15 minute observation precautions include: Self-injury minimal or strict, Combative/Dangerous minimal or strict, SAO Precautions, Elopement Precautions minimal or strict, and Contraband Precautions. 2. Line of Sight (LOS), 3. One-to-one (1:1). The categories are defined in the context of increasing levels of supervision and documentation requirements which address the severity level of the patient's condition or behavior. In the event the patient's known, observed, or reported condition or behavior necessitates immediate implementation of a special observation category, a licensed nurse may evaluate the patient, implement the appropriate special observation category, document in the progress notes, and notify the physician/LIP within one hour. The Physician/LIP will evaluate the patient in conjunction with the licensed nurse and write/give an order for the special observation category or discontinue the intervention implemented. The special observation category and rational therefore must be discussed at the next Interdisciplinary Treatment Team. This review must be documented per orders by the physician/LIP as soon as the patient's needs change.

A review of the facility's policy titled "Self-Injury Precautions", dated 12/2008, revealed the purpose was to provide guidelines for the use of interventions intended to prevent any self-inflicted injury. The policy was patients would be assessed for self-injury potential as part of the hospital's admission procedures. Staff will continue to assess the potential of each patient to engage in self-injurious behavior as part of ongoing clinical care. Patients believed to be as risk for self-injury will be placed on precautions that prescribe specific steps staff will take to reduce risk and provide treatment for the patient's condition. Additional intervention steps may be taken to address a particular patient's circumstance when authorized by a physician/LIP order. Self-injury precautions will be discontinued by a physician/LIP when clinically indicated and reviewed by the Treatment Team. Responsibilities: Direct Care Staff will monitor patients' behaviors and be alert at all times to the potential for self-injury in each patient. When self-injury intentions are believed to be present, staff will initiate precautionary measures and interventions immediately. Procedure: 1. At the time of admission and throughout hospitalization, a licensed nurse/physician/LIP will determine if there is a need to implement precautions to prevent self-injury. 2. When a patient is believed to be at risk for injuring themselves, specific precautionary interventions may be initiated by staff. These interventions are designed to maintain close supervision and monitoring of self-injurious or suicidal patients. A physician/LIP order for precautions be obtained by a licensed nurse within one hour and the patient will be evaluated by a Physician/LIP by the end of the next business day. 3. The need to continue self-injury precautions will be reassessed by the physician/LIP and in consultation with Treatment Team at least every 48 hours or the next business day. A physician/LIP order is required to discontinue the order prior to expiration. 4. Documentation in the Progress Notes will include the reason(s) for implementing, continuing, and discontinuing self-injury precautions. 5. Two level of self-injury precautions will be used to address the risk factors presented by the patient: Minimal Self-Injury Precautions - will be implemented for patients who present with a significant level of risk of self-injury.. Level of Observation ordered may be Q15 Minute Check or Line of Sight. A physician/LIP will conduct a face-to face evaluation of patients placed on minimal self-injury precautions by the end of the next business day. Patients will be visually monitored consistent with the level of observation ordered. The patient will sleep in an area where close observation can be provided. The patient may be restricted to the unit during periods of increased self-injury, or as directed by the Physician/LIP. Patients will have their person, room, and personal possessions examined for items which could be harmful. Room searches will be conducted every day and randomly while precautions are in place. The patient's face and extremities will be observable at all times. Certain items of clothing such as pants with zippers, etc. may be prohibited if these items present a potential danger. Shoes with laces will be prohibited on this precaution level. Patients will be observed for any mood, behavioral, and /or physical changes, If present, changes will be reported to supervisor and Physician/LIP. Direct Care Staff will document 15-minute visual checks on the Observational Flow Sheet. Nursing Staff will document in the Progress Notes each shift. Documentation will include staff observations and interventions, patient activities and behaviors. The patient will be allowed to participate in treatment activities.

A record review revealed Patient #4 was admitted to the facility on 12/11/12 with a
diagnosis of Major Depressive Disorder, Recurrent, Severe, without Psychosis. The reason for admission was hitting a family member on the head with a rock. In addition, the frequency of the 15 minute observation by staff was never altered during his/her course of stay. The patient had a history of swallowing a broken pencil which required surgery, attempting to choke self with sweatshirt, drown self in sink, and claimed to have drank liquid cleaner and of cutting self.

A review of the care plan for Patient #4, dated 12/11/12, revealed a care plan in place related to Suicidal Ideations and Self Injurious Behaviors. Further review revealed the patient had a history of swallowing a broken pencil which required surgery, attempting to choke self with sweatshirt, drown self in sink, and claimed to have drank liquid cleaner and of cutting self.

A review of the Shift Narrative Summary, dated 01/05/13 at 8:31 PM, revealed Patient #4 went to the "Treasure Store" to obtain a reward for successful completion of a specified behavioral opportunity. On return from the store, the patient "began horsing around" and staff instructed Patient #4 to stop. However, the patient did not stop the behavior and was escorted back to the unit by nursing staff and instructed him/her to go into the quiet room. Patient #4 refused to enter the quiet room and went to the personal bedroom where staff "put patient in a hold to get patient to the quiet room". Staff performed a search on Patient #4 and found fingernail polish. The summary stated the patient swallowed a half of a bottle of nail polish while staff tried to put Patient #4 in a hold and secure the nail polish.

A review of an Incident Report Form, dated 01/05/13 at 8:30 PM, revealed the youth care workers were instructed to get the nail polish from Patient #4 when the patient began to drink the polish and then threw the bottle at the wall.

An interview with Patient #4, on 03/01/13 at 7:00 PM, revealed the finger nail polish was thrown at the wall in the personal bedroom but the patient denied drinking the nail polish. The patient stated he/she acted like the polish was drank but did not want to be sick from actually drinking it. Staff were unaware at the time if the patient had drank the nail polish.

A review of an Incident Report, dated 02/16/13 at 9:15 PM, revealed Patient #4 reported to staff he/she had grabbed medication from the medication room while no one was looking. The resident stated she swallowed some and flushed some down the toilet. The incident report revealed staff found a cassette of Wellbutrin (anti-depressant) Slow Release 150 mg. in the toilet. Staff checked the cassette and determined approximately four to six pills were missing.

An interview with Registered Nurse (RN) #2, on 03/01/13 at 8:10 AM, revealed she was giving 8:00 PM medications when Patient #4 requested cough syrup. She stated she administered Patient #4 the cough syrup but never saw the patient enter the medication room. RN #2 could not recall when she was notified Patient #4 had taken medications from the Medication room but stated she was still passing 8:00 PM medications and Patient #4 was given medications near the end of the med pass.

A review of Patient #4's February 2013 Medication Administration Record (MAR) revealed Robitussin cough syrup was given on 02/16/13 at 7:45 PM.

An interview with Patient #4, on 03/01/13 at approximately 9:00 AM, revealed he/she went to the medication room on the unit to obtain cough medicine. Patient #4 reported when the staff turned her back to get the medication, Patient #4 reached into the room, removed a pill pack of Wellbutrin from the pharmacy return bin stationed at the end of the counter, and put it under his/her shirt. Patient #4 also reported he/she had taken 14 of the pills and tried to flush the remaining pills down the toilet. Patient #4 stated he/she was having hallucinations within ten minutes of taking the pills and reported what he/she had done to RN #1. He/she stated she gave RN #1 the pill pack containing five pills after he/she had pulled it out of the toilet. Patient #4 stated RN #1 did not believe he/she although there were only five pills remaining in the pack. Patient #4 stated there were only five pills missing from the top row of the pill pack before he/she had taken any of the medication. Additionally, Patient #4 stated the facility kept he/she on the same level of supervision and did not do anything else.

Interview with RN #1, on 03/01/13 at 8:40 AM, revealed Patient #4 reported he/she had taken some medications and flushed some down the toilet. The patient stated staff would find the rest of the pills and the package in the toilet. He revealed Patient #4 told him he/she got the medication package from the pharmacy return medication bin inside the medication room and went to the bathroom to take the pills. He stated when he recovered the medication package from the toilet, he recalled a maximum of 3-4 pills missing per his recollection of event. However, he confirmed the package was from stock medications being returned to the pharmacy and there were no counts performed on those medications prior to being put in the pharmacy return bin so there was no way to determine the exact number of pills missing.

Observation of the package retrieved from commode revealed five pills remaining and was labeled Wellbutrin SR 150 mg Tablet 30 tablets.

A review of the Shift Summary Note, dated 02/16/13 for 3:00-11:00 PM shift, revealed initial vital signs were taken at 9:30 PM and revealed a pulse of 108 beats per minute (BPM) and the patient complained of being unable to sleep. Further review of the Shift Summary Notes and Vital Sign Flow Sheet revealed from 9:30 PM to 3:15 AM, which was over a six hour period of time, the facility failed to monitor the patient's vital signs to check for tachycardia (elevated heart rate) as reported by the physician and pharmacist as a possible side effect of the ingestion of the Wellbutrin. The heart rate at 3:15 AM was 116 bpm and at 7:00 AM the heart rate was 120 bpm. Nursing notes from the third shift revealed Patient #4 reported seeing shadows in the hallway. The frequency of the patient observations was not changed and the resident remained on routine 15 minute observation throughout the night.

Interview with Mental Health Technician (MHT) #1, on 03/01/13 at 5:45 PM, revealed she spoke to Patient #4 after he/she had taken the medication. She stated the patient was jittery and was having trouble sleeping. She revealed she went down to check on the patient but was not aware of the patient being on any increased level of observation at the time.

Interview with Licensed Practical Nurse (LPN) #1, on 03/01/13 at 5:35 PM, revealed she was not aware of Patient #4 being placed on any increased supervision at any time.

Interview with Advanced Registered Nurse Practitioner (ARNP), on 03/01/13 at 9:20 AM, revealed he received a phone call related to Patient #4 taking the Wellbutrin SR 150 mg. tablets. He recalled RN #3 reported Patient #4 might have taken 4-5 pills. The ARNP stated the nurse denied the patient was having any symptoms at the time. He stated the patient would have experienced insomnia, tachycardia (increased heart rate) and elevated liver enzymes if he/she had taken the medication. He stated if the side effects were more serious he would have sent the patient to the Emergency Department for treatment. The ARNP stated he recommended staff increase the patients fluid intake during the night and ordered Q15 observation for suicidal ideation (SI)/ self- injurious behavior(SIB), minimal, until treatment team could meet on 02/18/13. He stated when he spoke to Patient #4 he/she reported he/she was not sleeping well. He revealed he ordered a complete metabolic panel to check liver enzymes and there were no abnormal laboratory results. No increased one to one supervision was provided to the patient as detailed by the facility's self injury precautions policy.

A review of the Physician's Orders, dated 02/16/13 at 9:00 PM, revealed Patient #4 was placed on Q15 minute checks for SI/SIB until treatment team meeting on 02/18/13.

An interview with the Pharmacist, on 03/01/13 at 10:32 AM, revealed the side effects expected with Wellbutrin SR would be confusion, hallucinations, and tachycardia. He stated if a patient was given one dose the patient should be cleared of symptoms in 24 hours. He stated he would have recommended staff watch the patient for symptoms and if the patient became confused or exhibited signs of hallucinating the staff should prevent the patient from acting on the hallucinations to prevent injury.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to have Schedule II medications in a double locked area. Observation revealed the keys were available behind a single locked door which allowed anyone who could gain admittance to the medication room access to the keys which would provide them with access to the Schedule II narcotics.
Findings include:
A review of the facility's policy, "Inspection of Medication Areas", dated 09/06 revealed the purpose of the inspection was to insure, at a minimum, the security of drug storage was verified (in a locked area, or if Schedule II medications - double locked area).
Observation during tour, on 1/27/13 at 7:10 PM, revealed the keys to the narcotics storage box which contained Schedule II medications were stored in an unlocked drawer in the medication room.
An interview with the Registered Nurse (RN), on 1/27/13 at 7:10 PM, revealed narcotics keys have always been kept in the drawer for as long as she had worked in the facility. She stated only one nurse has the key to the medication room at all times and it is transferred from nurse to nurse when the narcotics are counted between shifts.

Based on observation, interview, and review of facility's policy, it was determined the facility failed to have an inventory management system that ensured outdated medications were not available for patient use. One vial of outdated Benadryl 50 milligrams (mg.)/milliliter (ml.) was found in the Emergency Drug Kit (EDK) with other medication to be administered in an emergency.

The findings include:

A review of the facility's policy, "Inspection of Medication Areas", dated 09/06, revealed the purpose of the inspection is to ensure, at a minimum, outdated drugs are not in the inventory. The policy stated an appropriately licensed staff will make an inspection of all medication areas, at least quarterly.

Observation during the tour of the exam room, on 01/27/13 at 6:45 PM, revealed one vial of Benadryl 50mg/ml, with an expiration dated of 01/2013 in the emergency drug kit. The expiration date was verified by the Registered Nurse (RN) Supervisor.

Interview with the RN Supervisor, on 01/27/13 at 6:45 PM, revealed the third shift staff was supposed to check for expiration dates and return the expired medications to Pharmacy.

An interview with the Administrator, on 01/28/13 at 1:00 PM, revealed the third shift staff had a check list that included checking the EDK for outdated drugs, but the checklist had been overlooked and the EDK had not been getting checked for out of date medication.